Marmot 10 years on: the role of lifestyle medicine in reducing health inequality

Rob Lawson Posted by Rob Lawson on 27 Feb 2020 / Comments



Social media can be a powerful force for good in the world. At its best it connects people and enables the spread of ideas and information. At its worst it generates more heat than light and provokes division and even irrational enmity.

Online debate about how best to tackle health problems is a case in point. While there is plenty of enlightened and civil discussion there is also sound and fury. Social media platforms of course thrive on generating anger - but they also have a reductive quality. Debate all too often becomes binary, and false dichotomies quickly arise as people retreat into “us versus them” camps. This phenomenon in itself can have harmful implications for our health - especially on our mental wellbeing.

But it also doesn’t get us very far. There appears to be a particularly harmful false dichotomy emerging in discussions around lifestyle medicine at the moment - and its role in addressing health inequalities. I think this often arises as a result of a misunderstanding of what we mean by “lifestyle”. And I can see it rearing its head again this week on the publication of the new Marmot Review.

To summarise: needless division seems to be arising over a choice of emphasis. That is, whether we should emphasise individual lifestyle choices and behaviour when coming up with a strategy or the “wider determinants” of ill health, such as poverty and inequality. Or as Sir Michael Marmot puts it in his second report on Health Equity in England: “the conditions in which people are born, grow, live, work and age and inequities in power, money and resources.”

Lifestyle Medicine does not deliberately emphasise the former over the latter. And in my view, it doesn’t have to be either or. Both matter, and both are important if we are to understand all the determinants of disease and of health in the 21st Century. And they are often interlinked. An individual’s ability and motivation to make positive lifestyle choices to improve their health can often be helped or hindered by those “conditions”.

However, clinicians and other health professionals are not policymakers. While we can lobby and advocate for change - and we do - we cannot enact change at the societal level. Not on our own at least.

One element of this false dichotomy is yet another misrepresentation of lifestyle medicine as we see it. That somehow it seeks to blame or point the finger at people for poor lifestyle choices. This could not be further from the truth.

The British Society of Lifestyle Medicine, for example, advocates for supported and evidence-based behavioural change. We do not judge the person in front of us but start from a position which acknowledges the physical, emotional, environmental and social determinants of their ‘condition’ and how it is impacting on their quality of life and life chances. At whatever stage in life.

Lost decade

Marmot is right to highlight the last 10 years as potentially a lost decade from a health improvement perspective. Since 2011, continuous improvements in life expectancy have “slowed dramatically” … “almost grinding to a halt”. When Sir Michael wrote his original report in 2010 there was a gap of seven years in life expectancy between the richest and poorest parts of England. That has now widened to over nine years for men and just under eight years for women.

We have grown used to ever increasing life expectancy and improving health. And the UK had developed a reputation as a world leader in identifying and addressing health inequalities. The last decade, however, is a sobering wake up call. As Marmot puts it: we have “stopped improving”. Or worse, sliding backwards.

His latest report draws a direct link between societies with large social and economic inequalities and high levels of health inequality. Health services on their own cannot fix these inequalities, he argues without attempts to address the social determinants of health outlined above.

Some local authorities and communities have been good at tackling health inequalities, the report concludes - and the government now needs to build on these successful examples. I agree and we must follow up all the current talk of ‘levelling up’ with action.

Social isolation is an important part of this story and the BBC’s online coverage of the Marmot report highlighted a positive example from Coventry. There, a community cafe is providing more than just a place for people to get an affordable healthy meal. It is offering people hope, and a place for people to meet and socialise and share their experiences. One individual with depression spoke movingly about the important sense of community he began to get from attending the cafe and just talking to people. Increasingly adverse childhood experiences are being recognised as disease determinants. We need to be concentrating on this end of lifespan as well. That my five year old grandson potentially has a lesser healthy life expectancy than his father is a legacy of which we should be ashamed and by which we should be energised to achieve change.

As I said in my letter to the UK Prime Minister in December, BSLM believes government as well as individuals and communities are part of the solution. Realistic and system- wide approaches to countering the rise in lifestyle related disease are needed, with mainstream lifestyle as ‘medicine’ recognised as part of the solution at both individual and societal level.

Again, it’s not either or - and not the binary choice we are sometimes presented with on social media. We can make #1change at a time as individuals and as a society. Indeed we must, if we are to make progress in preventing, treating and even reversing the diseases which are related to the life in which we live - that’s where it starts.

If you'd like to engage in some in-person rather than online discussion of these critical issues why not join us for our annual conference in London from June 24th -26th 2020?